Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis

Ashish A Ankola; David K Bailly; Ron W Reeder; Katherine Cashen; Heidi J Dalton; Stephen J Dolgner; Myke Federman; Rod Ghassemzadeh; Adam S Himebauch; Asavari Kamerkar; Josh Koch; Joseph Kohne; Margaret Lewen; Neeraj Srivastava; Renee Willett; Peta M A Alexander

doi:10.3389/fcvm.2021.812881

Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis

Front Cardiovasc Med. 2022 Jan 13:8:812881. doi: 10.3389/fcvm.2021.812881. eCollection 2021.

Authors

Ashish A Ankola¹, David K Bailly², Ron W Reeder³, Katherine Cashen⁴, Heidi J Dalton⁵, Stephen J Dolgner⁶, Myke Federman⁷, Rod Ghassemzadeh⁸, Adam S Himebauch⁹, Asavari Kamerkar¹⁰, Josh Koch¹¹, Joseph Kohne¹², Margaret Lewen⁸, Neeraj Srivastava⁷, Renee Willett¹³, Peta M A Alexander^{14

15}

Affiliations

¹ Department of Pediatrics, Divisions of Critical Care and Cardiology, Baylor College of Medicine, Houston, TX, United States.
² Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, United States.
³ Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.
⁴ Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States.
⁵ Department of Pediatrics and Heart and Vascular Institute, Inova Fairfax Hospital, Fall Church, VA, United States.
⁶ Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Houston, TX, United States.
⁷ Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, United States.
⁸ Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
⁹ Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
¹⁰ Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States.
¹¹ Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States.
¹² Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States.
¹³ Department of Pediatrics, Children's National Hospital, Washington, DC, United States.
¹⁴ Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.
¹⁵ Department of Pediatrics and Harvard Medical School, Boston, MA, United States.

Abstract

Background: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry. Methods: All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression. Results: There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0-1.3, p = 0.02; OR 0.77, CI 0.6-0.9, p = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0-11.1, p < 0.001) and central cannulation (OR 1.75, CI 1.0-3.1, p = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15-7.08, p = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02-11.61, p = 0.047). Conclusions: Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.

Keywords: anticoagulation; bleeding; cardiac; extracorporeal membrane oxygenation; pediatric.